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FOR OFFICE US ,D APPLICATION FOR SANITATION PERMIT , ------------------------------------ Permit No. la•6� (Complete in Triplicate) S-IY ----------------------------------- " --------------____________ This Permit Expires 1 Year From Date Issued Date Issued ..Y: l3n7a Application is hereby made to the San Joaquin Local Health District for a permit to construct and install the work herein described. This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: _ t. JOB ADDRESS/LOCATION .. _ .__ f -- -12 --------------CENSUS tACT Owner's Name ---------51_o-=- ----------------------------------------------•----------- --- ---Phone --------------------------••-------- Address6� ---/�-e---a --�---------------------------------------- City - -- -- --------------------------/-•--•--- Contractor's Name -----XV-7,P--= _40�_/d�-e-------------------------------License #��', ,� z PhIri'e��.�_,-VZ/45� Installation will serve: Residence Apartment House❑ Commercial ❑Trailer Court ',❑ It ` Motel r7 Other -------------------------------------------- , r Number of living units:----C------ Number of bedrooms __��-_____Garbage Grinder _._ Lot Size Water Supply: Public System and name -------------------------------------------------------------J`-"---- ;---------------------------------------Private ❑ Character of soil to a depth of 3 feet: Sand'❑ Silt❑ Clay ❑ Peat❑ Sandy Loam ❑ Clay foam ❑ Hardpan ❑ Adobe K Fill Materiel . If yes', type ---------------s-___._-_____ [Plot plan, showing size of lot, location of system in relation to wells, buildings, ett'!a'must be placed onF reverse side.] NEW INSTALLATION: (No septic tank or seepage pit permitted if public sewer is available within 200.feet,) PACKAGE TREATMENT { ] SEPTIC TANK'[ ] Size----------------------------------------------__ Liquid Depth __________________________ Capacity ------ Type ____________________ Material---------------------- No. Compartments --------------------_- Distance to nearest: Well ------------------------------------Foundation ;--------------- Prop. Line ---------- .-..-.---- LEACHING LINE [ ] No. of Lines ------------------------ Length of each line-----------------------------Total Length ----------- ---------------- 'D' Box ------------ Type Filter Material --------------------Depth Filter Material• ..--------,--------- _------------------ Distance to nearest: Well _____________--_____ Foundation ------------------------ Property Line ----------------- ...... SE=EPAGE PIT [ ] Depth Diameter ---------------- Number ----------------------- ---- Rock Filled Yes [] No ❑ Water Table Depth -----------------Rock Size ----------------------------------- Distance ------------------'-----------Distance to nearest: Well ----------------------------------------Foundation ------.--------------- Prop. Line ---------------------- REPAIR/ADDITION(Prev. Sanitation Permit# -------------------------------------------- Date ---------------------------------- . Septic Tank (Specify Requirements) - --------------- -------------------------- /. ;`: Disposal Field (Specify Requirements) _ � `� 7, ---- 4C ---- _ f '�- - --�-------------------------------------------------------- .. .. ----------------- --------------------------- - ------------------------------------------------------------ ----- ---- (Draw existing and required addition on re erse side) t I hereby certify that I have prepared this application and that the work will be' done in accordance with San Joaquin County Ordinances, State Laws, and Rules and Regulations of the San Joaquin Local Health District. Home owner or licen- sed agents signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to Workman's Compen tion laws of California." Signed ------ ----- -------------------- - --- ------------------------------- Owner )t BY TitleiZ ------ -------------------------- (If r than owner) i FOR DEPARTMENT USE ONLY APPLICATION ACCEPTED BY ---- -------- ------ -- ---- - -------------- ----------------- DATE � � �---------- BUILDING PERMIT ISSUED -- ------------------------ -------DATE ------- ----- -------------- ---------- ADDITIONAL COMMENTS -------------- - ---r__ef------ ------ --- ---------- ' ----- ------------------------------- ------- ?------ -- -------- - -----------------------.--_-__------------------- ------------ --- ,r �1 ------ ` ------ ------------------------------------- -------------------- Final Inspection by: -------- �OAQUIN ------------------------------ - -----------------------Date --- SAN LOCAL HEALTH DFISTRICT E. H. 9 1-'b$ Rev. 5M ' r